Medication Safety: Deprescribing Jessica Visco, PharmD ... · August 24, 2016 Deprescribing Jessica Visco, PharmD, CGP SeniorPharmAssist Webinar #1 Webinar #6 Medication Safety: ...

DeprescribingJessica Visco, PharmD, CGP

SeniorPharmAssist

August 24, 2016

Deprescribing

Jessica Visco, PharmD, CGPSeniorPharmAssist

Webinar #1Webinar #6

Medication Safety: Preventing Adverse Drug Events and Improving Transitions of Care

Michael Crooks, PharmDJessica Visco, PharmD, CGP

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planning of the activity. If any arise, an announcement

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No commercial support has influenced the planning of

the educational objectives and content of the activity.

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not CE related.

Objectives

Define and classify medication errors and preventable

medication-related harms

Identify medication-related quality measures for various

care providers and settings

Identify opportunities to engage community pharmacists

in health care improvement

Explain the difference between medication therapy

management and medication management

List at least 3 community resources for medication

management

Case Mr. J is a 72 year old AA gentleman who comes in

today for his follow up medication review. His chief

complaint is pain and swelling in his left hand and arm.

He also reports no appetite and a general feeling of

malaise.

PMH

Arthritis and gout

Diabetes

Hypertension

Elevated lipids

Reflux

Case Current Medications

Hydrochlorothiazide 25mg daily

Carvedilol 25mg twice daily

Amlodipine 5mg daily

Aspirin 81mg daily

Simvastatin 40mg daily

Glipizide ER 10mg 2 daily

Vitals

BP 102/46 P 60 BG 579 (random)

“A medication error is any preventable event

that may cause or lead to inappropriate

medication use or patient harm while the

medication is in the control of the health care

professional, patient, or consumer.”

-National Coordinating Council on Medication

Error Reporting and Prevention (NCC-MERP)

Medication Errors Defined

“A medication error is any preventable event

that may cause or lead to inappropriate

medication use or patient harm while the

medication is in the control of the health care

professional, patient, or consumer.”

-National Coordinating Council on Medication

Error Reporting and Prevention (NCC-MERP)

Medication Errors Defined

Term Definition Example

Medication Error

An inappropriate use of a

drug that may or may not

cause harm (all are

considered preventable)

Incorrect dose selection, dosing at

wrong time of day, dose omission,

duplicate therapy, insufficient

monitoring, etc.

Potential Adverse

Drug Event

(pADE)

A medication error with the

potential to result in an ADE

which is detected before

reaching a patient

Long-acting sulfonylurea

(glyburide) ordered for patient

over 65 years old, or possible

drug interaction (warfarin and

antibiotic)

Adverse Drug

Event (ADE)

Harm resulting from medical

intervention related to a drug

(May be preventable or not preventable)

Hypoglycemia resulting from

glyburide use

Adverse Drug

Reaction (ADR)

Harm directly caused by a

drug at usual doses

(May be preventable or not preventable)

Allergic reaction to glyburide in

patient with ‘sulfa’ allergy

The Medication Error Continuum

Inappropriate

Use

May Cause

Harm

Potential Adverse Drug Event

(pADE)

Patient Injury

Adverse Drug Event (ADE)

Or

Adverse Drug Reaction

(ADR)

pADE

ADE

Medical Errors and Medication Errors:

Prevalence in the US Health System

1999 Institute of Medicine (IOM) report:

To Err is Human: 44,000–98,000 people/year die as a

direct result of medical errors

2016 Journal of Patient Safety

Deaths from Preventable Harms in Hospitals: New

estimate of 210,000 to >400,000 deaths per year

2006 Institute of Medicine report

Preventing Medication Errors: 1.5 million preventable

ADEs annually in the US. Average costs ~$8,750

Community and Post-Acute Care

Adverse Drug Events and Older Adults

2011 New England Journal of Medicine Emergency Hospitalizations for Adverse Drug

Events in Older Americans:

ADEs result in 265,000+ ED visits per year among adults 65 an older

100,000 of these required hospitalization

ADE rate 3.5x higher for 85+ vs 65-69 year old regardless of # of meds taken

265,000 ADE – ED Visits

100,000 result in

Hospital-ization

Community & Post-Acute Care ADEs:

Highest Risk Drugs in Older Adults

ADEs result in 265,000+ ED visits per year, 100,000 requiring hospitalization(2007-2009)

Warfarin 33.3% 46.2%

Insulins 13.9% 40.6%

Anti-platelet 13.3% 41.5%

Oral Hypoglycemics 10.7% 51.8%

Opioids 4.8% 32.4%

Beers List Meds* 3.2% 27.6%

% of Hospitalizations

% of ED Visits resulting in Hospitalizations

*Excludes digoxin, as 0.125mg dose is not considered a Potentially Inappropriate Medicine

The National Action Plan for Adverse Drug Event Prevention

U.S. Department of Health and Human

Services, Office of Disease Prevention and

Health Promotion , July 2014

Modeled after National Action Plan to Prevent

Healthcare-Associated Infections

Defines a framework for government and

non-government agencies to coordinate

efforts to reduce the health burden of ADEs

Significant ADEs for the Big 3

Anticoagulants: Bleeding Events

Diabetes Agents: Hypoglycemia

Opioids: Respiratory Depression and

Excessive Sedation

This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. [11SOW-QINNCC-00362-07/31/15]

This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. [11SOW-QINNCC-00362-07/31/15]

Medicine: Help and Harm“At least 80% of the way we prevent and control

disease is through the use of medications”

Drug-related harm costs >$200 Billion annually. More

than the cost of the drugs themselves

Medicare beneficiaries with chronic diseases:

See 13 physicians; Fill 50 different Rxs per year

76% of admissions; 100x rate vs no chronic disease

Only 33% to 50% of chronic condition patients adhere

to prescribed medication therapies

Medication Reconciliation in

Patient Care Settings

Inpatient (Hospitalization, Nursing Facility, Surgical Care)

Mandatory/Regulated/Best Practice

Many available systems or toolkits

Varying standardization and quality

Outpatient (Community Dwelling ± Care Assistance)

Not mandatory, not widely recognized as best practice

Few/minimally developed systems or toolkits

Varying standardization and quality (if it even occurs)

“Brown Bag” Medicine Reviews

Physical review of patient

medication supply

For Medication Reconciliation

and/or to identify medication

related problems

Possible strategy to perform

medication management services

Do Your PART: My Meds Bags

Order Bags for FREE at

www.alliantquality.org/content/orders

Why Pharmacists?

Specialized training in the properties and

management of medications

Interface between prescribing and

dispensing to resolve potential conflicts of

interest

Community pharmacists are the health

professionals most accessible to the public

Pharmacy Care Process

Describes the elements

of Pharmacy Care

Promotes consistency

across the profession

Create a framework for

care in any setting

Medication Error Prevention: Engaging the Community Pharmacist

Improving Medication Safety

Preventing Drug Interactions

Preventing Adverse Drug Events

Identifying Duplications of Therapy and Unnecessary Medications

Improving Medication Efficacy:

Reducing Medication Non-Adherence

Identifying Medication Omissions

Improving Patient Medication and Monitoring Self-Management

Hospital Readmission Reduction Program:30 Day Readmission Rate

All Patients

Discharged Medicare FFS Beneficiaries

Select Conditions

Select Condition DRG as 1

oDiagnosis

Readmission to Any Hospital for

Any Cause

Outcome Measure Denominator

Outcome MeasureNumerator

Population of Focus

Select Condition Diagnosis-Related Groups (DRGs) 2017:AMI, HF, pneumonia, COPD, CABG, THA/TKA

Hospital Readmission Reduction Program:30 Day Readmission Rate

All Patients

Discharged Medicare FFS Beneficiaries

Select Conditions

Select Condition DRG as 1

oDiagnosis

Readmissions

Medication Adherence

Discharge Medication

Confusion

Adverse Drug Events

Quality Improvement Opportunities

What factors increase risk of readmission?

Medications and Readmissions

Don’t fill or don’t take prescribed meds

10

and 20

Non-Adherence

Don’t stop taking discontinued meds

Duplication of therapy and drug interactions

Adverse Drug Events/Adverse Drug

Reactions

Dose confusion, improper monitoring

Pharmacy Solutions

Involve Pharmacist in Discharge Process

Perform medication reconciliation

Drug selection for generic/formulary coverage

Resolve duplicate/omitted medications

Patient counseling and education

Provide Medications at Discharge

Delivery to Bedside or Home, Ready Pick-Up

Care Coordination and Follow-up

Appointment reminders

Regular contact for adherence, side-effects,

self-monitoring

NQF #0092(a & b): Use of High-Risk Medications in the Elderly

All Patients

Medicare FFS Beneficiaries

Age 66+

Medicare, 66+ with any visit in past year

Rx claim for

(a) One HRM

(b) Two or more HRM

Outcome Measure Denominator

Outcome MeasureNumerator

Population of Focus

High-Risk Medications (HRM) from Beer’s Criteria List

NQF #0092(a & b): Use of High-Risk Medications in the Elderly

All Patients

Medicare FFS Beneficiaries

Age 66+

Medicare, 66+ with any visit in past year

HRM Use

Uncoordinated Care

Lack of Medication Reconciliation

Lack of Comprehensive Medication Review

Quality Improvement Opportunities

What factors increase risk of inappropriate medication use?

Potentially Inappropriate

Medications

High-Risk Medications in the Elderly (>65)

Beer’s Criteria List, START/STOPP Criteria

Increased ADE risk for certain medication

classes, extended duration or above

threshold doses

Includes prescription and OTC medications

Pharmacy Solutions

Medication Reconciliation and Coordination

of Care

Complete and accurate record of all Rx and OTC meds

Communicate medication list to all prescribers

Identify Potentially Inappropriate Medications

Comprehensive Medication Review

Medication Therapy Management (Medicare Part D

Benefit, self-pay or contracted service)

Review all medications and conditions to identify

medication-related problems

Develop Medication Care Plan with patient and MDs

How to Engage Pharmacy

Services

Identify the Pharmacies that serve your patients

Identify pharmacies offering enhanced services

Comprehensive Medication Review/MTM, Medication

Synchronization, Compliance Packaging, Delivery

Consider value proposal

Increased Referrals, Mutual benefits of Quality

Measure Improvement, contracted fee

Plan for sharing patient health information

With the pharmacy

With the patient

Medication Therapy

Management (MTM) Core elements of MTM

Comprehensive Medication Review

Personal Medication Record

Medication related Action Plan

Intervention and/or referral

Documentation and follow up

Senior PharmAssist (SPA) SPA provides four primary services to support the well-

being of Durham residents 60 and older:

1. Direct financial assistance

2. Medication therapy management

3. Tailored community referral and care management

4. Medicare insurance counseling (SHIIP Coordinating

site for Durham County)

919-688-4772

Duke Connected Care

Care Management Services Transitional care management

Chronic disease management

Connection to community

resources

Access to disability benefits and

social services

Home visits

In-clinic consultations

Medication adherence and

management

Transportation assistance

Medical home / primary care

physician (PCP) selection

Specialist e-consults

How To Refer:

1) Ambulatory Referral to DukeWELL in Maestro Care

2) In Basket Message to “DUKE WELL GENERAL” pool

3) Call (919) 660-9355

Who To Refer:

1) Eligibility for services depends on insurance

2) Refer patients with a PCP in DCC Network and screening will be completed to determine eligibility

Interagency Care Team (ICT) Target audience

GRTs

ICT members

Eligibility Criteria

60 and older

Dementia or other cognitive disorder

Recent or recurrent hospitalizations

Medication related problems

Referral – email [email protected]

Community Pharmacies MTM

Adherence packaging

Health education

Immunizations

Health screening

Delivery

Revisiting Mr. J Diabetes

Contacted his provider

Sent to the emergency room

Patient Assistance applications

Left arm pain

Gout

Urinary Tract Infection

Antibiotics

Summary

It is important to understand and identify medication errors and

adverse drug events, including the drug classes most frequently

associated with serious, preventable harm.

Learning medication-related quality measures and tips for

improving safe and effective medication use will improve patient

care.

Coordinating care with community pharmacist/pharmacies that

serve your patients will help decrease medication errors and

adverse drug events.

References:Slide #

4-7 National Coordinating Council for Medication Error Reporting and Prevention.

http://www.nccmerp.org/about-medication-errors. Web. 7/14/16

9 National Coordinating Council for Medication Error Reporting and Prevention.

http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf Web. July

14, 2016

10 Kohn, Linda T, Janet Corrigan, and Molla S. Donaldson. To Err Is Human:

Building a Safer Health System. Washington, D.C: National Academy Press,

2000. Print.

10 James, John T. A New, Evidence-based Estimate of Patient Harms Associated

with Hospital Care. Journal of Patient Safety 9.3 (2013): 122-28. Web.

10 Aspden, Philip. Preventing Medication Errors. Washington, DC: National

Academies, 2007. Print.

10,11 Budnitz, DS, et al. Emergency Hospitalizations for Adverse Drug Events in Older

14 Americans. N Engl J Med 2011;365:2002-12. Print.

References:Slide #

15,16 U.S. Department of Health and Human Services, Office of Disease

Prevention and Health Promotion. (2014). National Action Plan for Adverse

Drug Event Prevention. Washington, DC: Author.

17,18 High Risk Medication Classes: Hospital Admission and Readmission Rates.

Alliant Quality. Medicare Quality Innovation – Quality Improvement

Organization. North Carolina. 2017.

19 "The Patient-Centered Medical Home: Integrating Comprehensive

Medication Management to Optimize Patient Outcomes. 2nd Ed." Patient-

Centered Primary Care Collaborative, June 2012. Web. 12 Aug. 2016.

19 National Council on Patient Information and Education. Enhancing

Prescription Medicine Adherence: A National Action Plan. National Council

on Patient Information and Education. Rockville (MD).; 2007 Aug.

References:Slide #

22,23 The Role of the Pharmacist in the Health Care System. World Health

Organization. http://apps.who.int/medicinedocs/en/d/Jh2995e/, 1994. Web.

12 Aug. 201621 Pharmacists’ Patient care Process. Joint Commission of

Pharmacy Practitioners. http://jcpp.net/patient-care-process/; May 29, 2014.

Web. 15 Aug 2016.

25,26 Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/

medicare -fee-for-service-payment/acuteinpatientpps/readmissions-

reduction-program.html. Center for Medicare and Medicaid Services, 18

April 2016. Web. 15 Aug. 2016.

29,30 Measure #238 (NQF 0022): Use of High-Risk Medications in the Elderly –

National Quality Strategy Domain: Patient Safety. Center for Medicare and

Medicaid Services. https://pqrs.cms.gov/dataset/2016-PQRS-Measure-238-

11-17-2015/c2h5-33fn/data. 17 Nov. 2015. Web. 15 Aug. 2016.

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